Table of Contents
Introduction
Diarrhea is a subject matter which most of us will be familiar
with at some point in our lives, whether we travel or invade
the wilderness. It is a common ailment that rarely gets discussed
in any detail, mostly because it is self-limited in nature.
This means that our own body's defenses are usually capable
of warding off the many different types of agents of infection
that are known to be responsible for this condition. Diarrhea
is perhaps sometimes hard to define, but it has been said
that "you know it when you see it." For this reason,
we at Survive Outdoors believe that a photo would not be appropriate,
and will leave it to your imagination.
It is surprising in this day and age that we do not have
a great understanding of all the causes of most individuals'
diarrhea. If you look at any textbook, you will see a very
long list of causative agents (mostly infectious in nature).
Whenever you hear a physician say that your condition is "probably
due to a virus," this should be a red flag that medicine
has not done enough research or has not been able to develop
enough accuracy in determining the exact cause of the problem.
It is true that viruses cause many of man's ailments including
infectious diarrhea. However more recent studies would indicate
that bacteria are a very common source of diarrhea. For the
most part as mentioned, it is a self-limited disease process,
but on occasion can certainly be inconvenient and frequently
incapacitating, and on a rare occasion, potentially deadly.
Infectious diarrhea is contracted by food, beverage or waterborne
pathogens, either viruses, bacteria or parasites. Many travelers
to developing countries are familiar with "traveler's
diarrhea." This is a form of infectious diarrhea caused
by bacteria that does not seem to bother the intestines of
individuals who live in these countries. (Interestingly, when
these individuals travel to our country, they get a similar
form of traveler's diarrhea.) It seems our intestines become
accustomed to certain types of bacteria and when new species
are introduced by food or beverages we consume, we are at
risk for developing traveler's diarrhea.
Outdoor enthusiasts are perhaps more familiar with Giardia,
which is a protozoa microorganism. This is commonly found
in most North American fresh bodies of water. It can cause
severe cramping and abdominal pains with foul smelling, watery
stools.
Prevention is the first step in limiting one's exposure to
any infectious agent, including those that cause infectious
diarrhea. Sound food preparation and handling are key. For
the outdoors enthusiast, this means making sure that you have
adequate potable water with you for preparing food, drinking
and personal hygiene, including brushing your teeth. For limited
excursions, carrying your own water may be reasonable, but
for longer excursions, it is important to have some type of
water purification system available to you. Traditionally,
iodine tablets have been used and are highly effective, but
often leave a bad taste and are not indicated for individuals
with certain medical conditions such as thyroid disease or
pregnancy. Heating water to be used for personal use works
well, but you need to have a fuel source. If there is not
a weight or space concern, this method is best. You need only
bring the water to a boil (even at altitude) for microorganisms
to be killed. It is not necessary to "boil" the
water for a few minutes. This is simply a waste of fuel. Good
hand washing and use of anti-microbial detergent or soap should
always be employed when cleaning utensils, as well as your
hands. If you are traveling to an exotic locale or developing
country, prevention is still important. Although hotels, etc.
may have all appearances as their counterparts in the U.S.,
realize that the water sources that are used may be questionable
or poorly monitored, and that the individuals who work in
these institutions may not practice good personal hygiene.
The cook or waiter who makes your fine meal served to you
in the dining room may go home to a residence that has no
toilet or running water. So, it is good practice to eat food
that is hot, boiled, peeled or cooked. Use only bottled water
and avoid ice or food items that have been simply washed (salads,
fruits).
What to do if prevention is ineffective? The range of treatment
options depends on the source. For those with limited but
inconvenient diarrhea, loperamide is available over-the-counter
and very effective for most individuals. It should not be
used for prevention, but only for treatment of bothersome
and symptomatic diarrhea. For those on prolonged excursions
where medical help won't be routinely available, the appropriate
selection of antibiotics (and other anti-microbial medicines)
I believe are a necessary part of your medical kit. You should
discuss with your medical provider medications you should
have with you and when and how they are to be used in the
event of a significant intestinal infection.
When should you seek medical help? Certainly when dehydration
is a possibility because of frequent diarrhea, or when fever,
abdominal pain or bloody stools are noted. These symptoms
herald a potentially serious infection that needs to be evaluated
and treated emergently. One should not wait and see if it
resolves on its own or with symptomatic treatment.
What to do if medical help is not immediately available?
Trying to keep the patient hydrated even in the presence of
vomiting can be highly effective. Re-hydration solutions are
available, but any liquid given in small amounts frequently
may help stave off dehydration, even when vomiting is a prominent
feature. Additional anti-emetic (anti-vomiting) medication
should be part of your medical kit for those departing on
longer trips. If you have been provided appropriate anti-microbial
medications, using these at the first sign of worrisome symptoms
can be curative.
Being prepared is the hallmark of a wise traveler. Having
a good plan in advance and bringing with you the necessary
supplies to both prevent, and if necessary treat diarrheal
illness will hopefully contribute to a spiritually moving
experience as opposed to an intestinally moving one (pun intended.)
Feel free to send us any questions
you may have.
Cryptosporidium Parvum
Cryptosporidium is a protozoa that also causes infectious
diarrhea, and is commonly found in contaminated water. It
is characterized by severe watery diarrhea that may be accompanied
by a low-grade fever. In general, it is a self-limiting illness,
and if left untreated usually lasts 2-4 days. Outbreaks are
frequently seen in daycare centers. Common symptoms include
cramping, nausea and weight loss and usually develop 4-6 days
post ingestion, although symptoms may develop as long as 10
days afterwards. Bloody stools are uncommon.
Cryptosporidium is spread mainly by oral contact with contaminated
objects, by drinking polluted water, eating unwashed vegetables
and swimming in contaminated water and getting small amounts
of water in your mouth.
It is a myth that you cannot get cryptosporidium from chlorinated
pools, although it is less common. Filtering or boiling water
when camping is extremely effective in neutralizing cryptosporidium.
Cryptosporidium Parvum Treatment
Healthcare Provider - Medical Treatment
Cryptosporidium is a protozoa responsible
for many cases of diarrhea every year. It is commonly spread
by different animals, specifically cows, deer, domesticated
cats and dogs. It is important to note that for purification
purposes, Cryptosporidium is for the most part resistant to
iodine purification. It can be identified through acid-fast
staining, which confirms the diagnosis.
Treatment as per the Sanford Guide
to Anti-microbial Therapy, 2004, recommends trying Paromomycin
plus Azithromycin. Recommended dose is one gram of Paromomycin,
2x/day, and 600 mg. of Azithromycin once/day. It does appear
that Alinia may be very effective against Cryptosporidium.
The Sanford Guide is recommending 500 mg. to a gram 2x/day
for 2 weeks, and the pediatric dose is 100-200 mg. 2x/day
for 3 days.
Campylobacter Jejuni
Campylobacter is an infectious bacteria causing severe diarrhea.
Bloody diarrhea is commonly seen in infected individuals,
as in individuals infected with E. Coli, but unlike diarrhea
resulting from cryptosporidium and Giardia contamination,
as discussed earlier. Nausea and vomiting are also common
symptoms. The main cause of Campylobacter is ingesting infected
poultry and eggs. Un-pasteurized milk is another source of
Campylobacter. Therefore, it is important if bringing along
poultry, other forms of meat, and eggs when camping, that
it is thoroughly rinsed and adequately cooled. As heat does
kill this organism, if is important to thoroughly cook meat.
Also, make sure you wash your hands frequently and thoroughly
during and after handling food products.
Infected individuals should drink plenty of fluids so that
they do not get dehydrated. Medications such as Erythromycin
or other antibiotics called Fluoroquinolones may shorten the
duration of the illness. Most individuals recover completely
without any treatment in approximately 5-7 days, but it may
take up to two weeks to resolve. For further information,
go to www.cdc.gov and look under Campylobacter.
Campylobacter Jejuni Treatment
Healthcare Provider - Medical Treatment
Campylobacter Jejuni is a gram-negative
bacillus that is responsible for many cases of diarrhea every
year. Treatment as recommended by the Sanford Guide to Anti-microbial
Therapy, 2004: Ciprofloxin, 500 mg., one, 3x/day for 5 days
or Azithromycin, 500 mg./day for 3 days has been found to
be very effective. You can also use Erythromycin, 1-2 grams/day
in four divided doses. It is also important to note that Campylobacter
is usually self-limiting and the infected individual will
become asymptomatic in 5-7 days. However, these medications
will eradicate it more quickly. Side-note: In Thailand, as
recently as last year, resistance to Quinolones when used
to treat Campylobacter has been noted.
Giardia Lamblia
Giardia is the most common parasite in the United States
and Canada. Incubation period is approximately 3 weeks. The
patient usually presents with malodorous diarrhea, which can
be explosive and watery. It may last for 3-4 days. History
provided may provide important clues regarding exposure, such
as a history of camping, drinking well water, travelers return
from endemic areas, etc. Giardia is more commonly being seen
in daycare settings.
Boiling kills the parasite instantly. You do not have to
boil the water for 5-10 minutes. As soon as the water comes
to boil, the parasite is killed.
Labs for Ova and parasites (O & P) can produce falsely
negative results, and testing is very expensive. Survive Outdoors
recommends to the medical provider to hold off on these until
the patient presents with any of the following:
- Patient with bloody stools.
- Patient who handles food as part of their job.
- Patient with a high fever.
- Patient with immuno-compromise.
- Patient with history of antibiotic use as you have to
be concerned about C-Dificile.
Giardia Symptoms
Incubation period is 1-3 weeks after ingestion of contaminated
water, although in general, symptoms do not occur before 2-3
weeks. Symptoms include diarrhea, increased gas, stomach cramps
and fatigue. Bloody and watery stools, often seen as a result
of infection from the bacteria such as E. Coli, are uncommon.
Nausea and increased abdominal noiseare also commonly seen.
Survive Outdoors frequently instructs individuals that if
they are lost in the woods, to go ahead and drink the water
rather than risk death from dehydration. Once found, medical
treatment for Giardia should be sought, although symptoms
most likely will not have begun to manifest themselves.
Giardia Treatment
Healthcare Provider - Medical Treatment
Metrodiazole (Flagyl) is an excellent
medication. Fluid intake should be increased slowly; for example,
a tablespoon of Gatorade or other liquids every ten to fifteen
minutes. Given the loss of fluid from diarrhea, great care
must be taken that affected individuals do not become dehydrated.
There are great water filters available on the market that
can filter out the protozoa Giardia, and therefore excellent
to take with when camping or fishing. Survive Outdoors highly
recommends these in order to avoid contact with the Giardia
organism.
Metronidazole, 250 mg., 3x/day for 5 days,
or 2 grams at bedtime for 3 days, as recommended in the Sanford
Guide to Anti-microbial Therapy, 2004. For years, Metronidazole
was not approved for children. Nitazoxanide (Alinia) has been
very effective in children. The dose is 1 tsp. for ages 12-47
months, or 2 tsp. For ages 4-11 years old. This is given 2x/day
with food for 3 days.
Studies have found that Alinia is not only
effective with Giardia, but very effective with Cryptosporidium,
84% effective with all the protozoans and 95% effective with
Helminths. This author has used this medication on two occasions,
and has had very good success with it.
Alinia (Nitazoxanide)
Alinia (Nitazoxanide) is a relatively new anti-parasitic
specifically in the treatment of children diagnosed with Giardia
or Cryptosporidium. Both are water-borne bacteria. This is
a relatively safe anti-parasitic. As per the Alinia website,
7.8% of patients did experience some abdominal pain, while
only 2% experienced diarrhea, 1% vomiting, and 1% headache.
Recommended age is 1-11 years. Benefits: It does have a pleasant
strawberry flavor, and it does not have to be taken for as
long as Flagyl. The current treatment guidelines are 1 tsp.
2x/day for 3 days. It is advised to take this medication with
food. For more information, please go to www.alinia.com. |
